Medicare Compliance & Reimbursement

Documentation is key to ensuring clean claims.

As the year starts to wind down, your practice is likely preparing for the 2021 E/M requirements. However, that doesn’t mean you should ignore the existing rules in 2020. In fact, accurate coding when 2021 starts can only happen if you get your documentation in check right now.

Remember: Services other than outpatient/office visits will still require the current level of service elements next year. Therefore, it’s a good idea to refresh your skills on what’s required from a documentation standpoint, so you can continue coding accurately.

One area that tends to trip up even the most seasoned coders is the history of present illness (HPI). HPI is an element within the history component — one of the three key factors used in selecting the correct level of E/M service. The CPT^® code book defines HPI as “a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present” and goes on to identify eight individual HPI elements.

Fun fact: You can remember those elements using the mnemonic SOCRATES:

• Site (Location): The anatomical place or site of the chief complaint
• Onset (Duration): Length of time of the complaint
• Context: The circumstances/environment in which the symptoms occur
• Radiation (Quality): How the complaint feels (stabbing, achy, itchy, better, worse, etc.), and where the symptom may spread
• Associated signs and symptoms: Other related factors or symptoms, positive or negative
• Timing: How often the symptoms occur (frequently, occasionally, etc.)
• Exacerbating/alleviating (Modifying factors): Anything that relieves or aggravates the problem
• Severity: The degree of intensity of the signs or symptoms (1-10 pain scale, wincing, doubled over in pain, etc.)

There are two levels of HPI: brief and extended.

First: For a brief, problem-focused, or expanded problem-focused HPI, the documentation needs to include one to three of the above elements.

Second: For an extended, detailed, or comprehensive HPI, the documentation needs to include four or more of the above elements. The 1997 E/M Documentation Guidelines also allow the provider to document the status of three or more chronic conditions, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Unfortunately, coding HPI isn’t always as simple as reading through the history and finding the required elements. It can be tricky to pinpoint the best HPI level. Check out three myths and the subsequent advice to boost your HPI coding.

Myth 1: Just Listing the HPI Element or Chronic Condition Is Sufficient

Not so, Pohlig says. Just listing is not enough. Your provider needs to document the status of each condition for the condition to count. For example, the notes might say, “Since the last visit, the patient’s GERD has been well controlled with diet without need for medications.”

Equal attention is required when choosing to document the HPI elements, Pohlig says. For instance, you cannot simply check off “Evaluated site, timing, and severity of the patient’s stomach issue.” You should instead get detailed, saying, “The patient describes an ‘always full’ sensation in the upper part of his stomach, which happens all day long, even upon fasting. The discomfort occasionally turns to pain, which has reached an 8 on the 1-10 pain scale.”

Myth 2: Duration Is Not Regarded as an HPI Element

Technically, this is true. The CPT^® guidelines state that HPI should include “a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms.” The list contains no mention of onset or duration.

However, the Centers for Medicare & Medicaid Services (CMS) does recognize duration as a separate element of HPI. Most auditors go by CMS standards regarding HPI because they are the highest guideline out there. All Medicare contractors and most other carriers follow these guidelines, too. In addition, it is appropriate to consider “timing” as relating to onset/duration.

Remember: If you are unsure of a payer’s HPI element list, you can check your contractual agreement, which should identify the recognized guidelines, Pohlig says. “If not mentioned, you can call your representative to check, and then document the response.”

Myth 3: You Can Document Chronic Conditions Instead of HPI

This is where the 1995 and 1997 Documentation Guidelines get muddied. If you are using the 1995 guidelines, documenting chronic conditions is not acceptable. Under 1997 guidelines, however, you can use status of one or two chronic medical problems instead of one to three HPI elements for a brief problem-focused or expanded problem-focused HPI, and status of three chronic medical problems instead of four HPI elements for an extended, detailed, or comprehensive HPI.

Golden rule: Your provider has to obtain this portion of the history. In many offices, the clinical staff will list the chief complaint and maybe even a couple statements. However, the provider will need to perform and document the HPI portion of the service for it to count in an audit.